|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
When a visit is reported for both a psychiatric and a non-psychiatric diagnosis and the description of service does not specify that psychiatric treatment was provided, the service should be processed as medical care.
In determining whether a particular service furnished to a patient with Alzheimer's disease or Tourette Syndrome is subject to psychiatric reimbursement guidelines, the nature of the service must be considered. Typically, treatment of patients with Alzheimer's disease or Tourette Syndrome will represent medical management of the patient's condition (e.g., treatment with medication), and should not be considered psychiatric treatment. However, where treatment is primarily psychotherapy, it should be considered psychiatric treatment.
NOTE: Claims for psychological testing/central nervous system testing (96101, 96102, 96103, 96105, 96111, 96116, 96118, 96119, 96120 and 96125) should be processed as a medical benefit or a psychiatric benefit, based on the patient's diagnosis (i.e., medical diagnosis or psychiatric diagnosis), regardless of the specialty (e.g., psychiatrist, psychologist) of the provider reporting the service.
Psychiatric diagnoses/conditions are listed in the Table Attachment.
Please refer to Medical Policy Bulletin V-37 for information on autism spectrum disorders.
Experimental/Investigational (E/I) services are not covered regardless of place of service.
A network provider cannot bill the member for the non-covered service.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.